Authorization Nurse, RN - 24-118

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At Hill Physicians Medical Group, we're shaping the healthcare of the future: actively managed care that prevents disease, supports those with chronic conditions and anticipates the needs of our members.

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Hill Physicians has much to offer prospective employees. We're regularly recognized as one of the "Best Places to Work in the Bay Area" and have been recognized as one of the "Healthiest Places to Work in the Bay Area." When you join our team, you're making a great choice for your professional career and your personal satisfaction.

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At PriMed, your uniqueness is valued, celebrated, encouraged, supported, and embraced. Whatever your relationship with Hill Physicians, we welcome ALL that you are.

We value and respect your race, ethnicity, gender identity, sexual orientation, age, religion, disabilities, experiences, perspectives, and other attributes. Our celebration of diversity and foundation of inclusion allows us to leverage our differences and capitalize on our similarities to better serve our communities. We do it because it's right!

Job Description:

Evaluate authorization requests and authorize, modify or pend per appropriate criteria. Refer authorization requests not meeting criteria to specialty physician reviewer according to established medical necessity, benefit and eligibility criteria to assure appropriate, efficient and timely medical care.

Job Responsibilities

• Review and process urgent and non-urgent authorization requests (via phone, fax and electronic submission) for medical necessity (according to established criteria) and authorize, pend or modify as appropriate.

• Obtain additional medical information as necessary from requesting provider.

• Communicate with providers and members regarding status of authorization requests.

• Collaborate with Medical Directors and other designated physician leaders for making clinical decisions.

Additional Responsibilities

• Review and process urgent and non-urgent authorization requests (via phone, fax and electronic submission) for medical necessity (according to established criteria) and authorize, pend or modify as appropriate.

• Utilize a variety of medical necessity, contractual and benefit criteria to determine appropriate authorization decisions. Criteria may include Milliman Care Guidelines, Hill Guidelines, Health Plan Criteria, Health Plan and Hill Physician contracted provider data and member benefit information.

• Obtain additional medical information as necessary from requesting provider.

• Communicate with providers and members regarding status of authorization requests.

• Assist interdepartmental staff members to resolve issues relating to the authorization process.

• Refer information regarding members to other departments as appropriate for follow-up (i.e., Case Management, Health Education, TPL, COB).

• Process authorization requests (routine, urgent and retrospective) according to department performance standards.

• Support Medical Management team authorizations, clinical initiatives, provider education, and other special projects as assigned.

• Collaborate with Medical Directors and other designated physician leaders for making clinical decisions.

• Participate in on-call or alternate work hour programs as needed to meet regulatory compliance requirements.

• Perform other duties as assigned by supervisor/manager.

• Assist interdepartmental staff members to resolve issues relating to the authorization process.

• Refer information regarding members to other departments as appropriate for follow-up (i.e., Case Management, Health Education, TPL, COB).

• Support Medical Management team authorizations, clinical initiatives, provider education, and other special projects as assigned.

• Participate in on-call or alternate work hour programs as needed to meet regulatory compliance requirements.

Knowledge, Skills and Abilities

Required Experience -

• Minimum three years clinical nursing experience.

• Utilization Management experience preferred.

• Excellent verbal and written communication skills.

• Ability to work effectively with a variety of customers including physicians, office staff, and members.

• Ability to work independently with self-initiative and discipline.

• Working knowledge of personal computers.

• Managed care experience and certification preferred.

• Knowledge of ICD-10 and CPT coding.

• Optimum organizational skills with ability to meet expected and unexpected time frames.

Required Education

Active, unrestricted California Licensure: Registered (RN) or Licensed Vocational Nurse (LVN).

Additional Information

Salary

$84,900 - $118,000

Hill Physicians is an Equal Opportunity Employer